Guidance for conducting a country COVID-19 intra-action review (IAR): addendum 1, 28 April 2021

Page 1 of 6 28 APRIL 2021 GUIDANCE FOR CONDUCTING A COUNTRY COVID-19 INTRA-ACTION REVIEW (IAR) ADDENDUM 1 KEY MESSAGES 1. This publication (Addendum 1) does not replace, but rather supplement the Guidance for conducting a country COVID-19 intra-action review (IAR) that was published on 23 July 2020 and that can be found at this link: https://www.who.int/publications/i/item/WHO-2019-nCoV-Country_IAR-2020.1. 2. The purpose of this addendum is to provide additional advice and to introduce new and updated tools based on the current global COVID-19 situation and the feedback received from countries that have successfully conducted IARs. 3. The addendum proposes new directions for conducting COVID-19 IARs moving forward, including conducting IARs for standalone response pillars, such as COVID-19 vaccination IARs, and for planning a COVID-19 after action review (AAR) once countries decide to transition from an emergency response to a recovery phase. 4. All IAR tools published on 23 July 2020 have been updated and replaced with new versions, with additional public health response pillars and topics, and supplemented with new tools that were developed based on feedback received from technical experts from WHO headquarters, regional and country offices, as well as partners. 5. It is likely that additional addendums may be published in the future, depending on how the COVID-19 pandemic evolves and based on the new developments or innovations in the global COVID-19 response. Page 2 of 6 1. BACKGROUND Recognizing that the COVID-19 pandemic would continue to be a protracted public health emergency, WHO developed and published the Guidance for conducting a country COVID- 19 Intra-Action Review (IAR) and ten accompanying templates and tools on 23 July 20201,2. This guidance intends to help countries conduct focused, periodic reviews to recalibrate and improve their ongoing response. Following the guidance publication, numerous countries have successfully conducted IARs and customized the review process to their unique needs, including introducing other public health response pillars that became more relevant as the COVID-19 pandemic evolved. This has allowed countries to identify immediately implementable activities to improve their response within their specific contexts. The objective of this addendum is to provide additional directions based on the evolving COVID-19 situation globally and feedbacks received from countries around the scoping and sustaining IARs as a repeatable process during a protracted emergency. Feedback received from technical experts at the WHO headquarters, regional and country offices, and partner agencies were also incorporated in the development of this addendum, additional tools and pillars. This addendum does not replace the existing Guidance for conducting a country COVID-19 intra-action review (IAR). Specifically, this document also proposes new directions for conducting COVID-19 IARs moving forward, and for planning the conduct of a COVID-19 after action review (AAR) once countries decide to transition from an emergency response to a recovery phase. 2. CONDUCTING COVID-19 IARS MOVING FORWARD More than one year following the official declaration of COVID-19 as a public health emergency of international concern (PHEIC) on 30 January 20203, the conduct of IAR remains as relevant as ever regardless of the specific response context and whether a review has been already conducted or not. Such review allows countries to take stock of what happened so far, to identify and implement a manageable number of targeted activities that address the gaps in the response, as well as to focus on aspects of the response that are more time-sensitive (e.g., the introduction of COVID-19 vaccines to different priority population groups, adjustment of public health and social measures as the epidemiological situation changes…etc.). 2.1. Conducting a COVID-19 IAR for the first time If a country has not had the opportunity to conduct a review of one or several pillars of their COVID-19 response, it is recommended that the country uses the WHO country COVID-19 1 World Health Organization. Guidance for conducting a country COVID-19 intra-action review (IAR). July 23, 2020. https://www.who.int/publications/i/item/WHO-2019-nCoV-Country_IAR-2020.1 2 Mayigane LN, Chiu de Vázquez C, Vente C, Charles D, Copper FA, Bell A, Njenge HK, Schmidt T, Samhouri D, Htike MM, Kato M, Stephen M, Van Kerkhove MD, and Chungong S. The Necessity for Intra-Action Reviews during the COVID-19 Pandemic. Lancet Global Health 2020; 8(12): E1451-E1452. 3 World Health Organization. (2020) Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). https://www.who.int/news-room/detail/30-01-2020- statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak- of-novel-coronavirus-(2019-ncov) Page 3 of 6 intra-action review guidance and its updated tools. The IAR can help key authorities and leaders recalibrate the next phase of the response through a number of priority actions. The IAR toolkit will be regularly updated to incorporate new elements related to the COVID- 19 response, so it is advisable to visit the IAR webpage before conducting COVID-19 IAR to download the most updated guidance and tools before embarking on the review process. 2.2. Conducting subsequent COVID-19 IARs If the country has already conducted a COVID-19 IAR, the following three actions are recommended: 1. Leverage the implementation progress of the critical activities/ recommendations from the previous IAR(s). These may include changes to strategies, policies, and processes or the development of new capacities to respond to the COVID-19 outbreak. To clarify persistent gaps or successes, assess whether recommended activities had the expected benefit on the response and whether they remain relevant or should be revised. 2. Identify opportunities to design your IARs to be more targeted in their scope to allow stakeholders in your response to be focused and agile. For example: o Select specific response pillar(s) based on their criticality at the particular stage of the outbreak based on your analysis of data and stakeholder interests; o New elements of the response that may not have been reviewed or were not yet in place during previous IAR(s) such as COVID-19 vaccination roll-out4, management of infodemics, addressing vulnerable and marginalized populations during the pandemic, national legislation and financing, adjusting public health and social measures, and examining workforce and operational resiliency as countries transition from COVID-19 response to recovery5; or o Sub-national review to enable more tactical and operational analysis for precise adjustments to the response in high-priority/risk areas. 3. Anticipate the need to periodically conduct IARs (e.g., every three months) during a protracted emergency. The first IAR will likely be more time and resource-intensive; however, by embedding repeatable processes and tools and targeting the focus of the analysis, subsequent reviews can be a lighter undertaking. 3. COVID-19 IAR: UPDATED AND ADDITIONAL MATERIALS The country COVID-19 IAR guidance is available in Arabic, Chinese, English, French, Russian, Spanish and Portuguese. Through this addendum, to supplement the published guidance, we have introduced new pillars. The first 10 pillars were developed in line with the updated COVID-19 SPRP. Additional pillars and topics emerged from feedback received from countries which successfully conducted IARs. These pillars were further developed in consultation with technical experts from WHO headquarters, regional and country offices as well as partners. 4 Copper FA, Chiu de Vázquez C, Bell A, Mayigane LN, Vedrasco L and Chungong S. Preparing for COVID-19 vaccine roll-out through simulation exercises. Lancet Global Health 2021; https://doi.org/10.1016/S2214-109X(21)00051-6 5 Greiner AL, Nguyen L, Shamout M, Krishnan S and Stowell D. COVID-19 intra-action reviews: potential for a sustained response plan. Lancet Global Health 2021; https://doi.org/10.1016/S2214-109X(21)00078-4 Page 4 of 6 The following different elements have been provided to support countries to conduct COVID- 19 IARs: 3.1. COVID-19 IAR Toolkit:  Original toolkit composed of 10 tools published in July 2020 (available in Arabic, Chinese, English, French, Russian, Spanish and Portuguese)  Updated generic COVID-19 IAR trigger questions database (tool #5) with new pillars and additional questions: # Pillar Update 1 Country-level coordination, planning and monitoring Additional questions 2 Risk communication, community engagement, and infodemic management Additional questions 3 Surveillance, case investigation and contact tracing Additional questions 4 Points of entry Additional questions 5 National laboratory system Additional questions 6 Infection prevention and control Additional questions 7 Case management and knowledge sharing about innovations and the latest research Additional questions 8 Operational support and logistics in the management of supply chains and workforce resilience Additional questions 9 Strengthening essential health services during the COVID-19 outbreak Additional questions 10 COVID-19 vaccination New pillar 11 Vulnerable and marginalized populations New pillar 12 National legislation and financing New pillar 13 Public health and social measures New pillar 14 Other possible topics and cross-cutting issues Additional questions  Updated or new IAR tools: 1. Tool #7a Generic final report template (updated) 2. Tool #11 Conducting safe onsite COVID-19 Intra-Action Reviews during the pandemic (new) 3. Tool #12 Conducting effective online COVID-19 Intra-Action Reviews during the pandemic (new)  New IAR tools specific to COVID-19 vaccination pillar: 1. Tool #6b COVID-19 vaccination-specific note-taking template (new) 2. Tool #7b COVID-19 vaccination-specific final report template (new) Note: Please note that for the COVID-19 vaccination pillar, specific note-taking final report templates have been customized and provided. The areas considered in the trigger question database, note-taking and final report templates for this pillar align with the National Deployment and Vaccination Page 5 of 6 Plan for COVID-19 Vaccines (NDVP) 6 and the COVID-19 vaccine implementation Post-Introduction Evaluation (cPIE) Strategy and have been developed in collaboration with WHO UHC/IVB/EPI team and the COVAX Country Readiness and Delivery Team. 3.2. COVID-19 IAR Training and supplementary materials:  An online training on the planning and conduct of a COVID-19 IAR is available on OpenWHO (available in Arabic, English, French, Russian, Spanish and Portuguese).  A COVID-19 IAR introductory video is also available to understand the IAR methodology in a few minutes (available in Arabic, Chinese, English, French, Russian, Spanish and Portuguese).  A COVID-19 IAR Frequently Asked Questions (FAQ) will also be available on the IAR website and will be updated as needed or if requested. 4. TRANSITIONING FROM COVID-19 IAR TO COVID-19 AAR The International Health Regulations Monitoring and Evaluation Framework7 recommends that Member States conduct an after action review (AAR) within 3-month of the end of the response to a public health event. As scientists worldwide predict that COVID-19 is likely to become endemic or a seasonal disease8, countries may gradually transition from an acute emergency response management approach to the mainstreaming of COVID-19 management into the health system. It is possible that some countries may never be able to officially declare the end of the COVID-19 outbreak. Therefore, it is important for countries to already identify triggers for the conduct of a COVID-19 After Action Review (AAR). These triggers could be based on:  The national context: such as the deactivation of the COVID-19 Incident Management System in the Public Health Emergency Operations Centre in the country, a specific request by the government, the achievement of a predefined vaccination rate in the population, the attainment of a specific epidemiologic threshold, and social or economic indicators.  The international context: such as the declaration of the end of PHEIC by the WHO Director-General upon the advice from the IHR Emergency Committee on COVID-19. These are just some examples of potential triggers that countries can consider when deciding whether a COVID-19 AAR should be conducted and may still need to be aligned with the emergency management framework adopted in the country for COVID-19. 6 World Health Organization. (2020) Guidance on developing a national deployment and vaccination plan for COVID-19 vaccines. https://www.who.int/publications/i/item/WHO-2019-nCoV-Vaccine_deployment-2020.1 7 World Health Organization. (2018) International Health Regulations (2005) Monitoring and Evaluation Framework. https://apps.who.int/iris/bitstream/handle/10665/276651/WHO-WHE-CPI-2018.51- eng.pdf?sequence=1%EF%BC%8C201R9%E5%B9%B44%E6%9C%8816 8 Phillips N. The coronavirus is here to stay — here’s what that means. Nature 2021; 590:382-384 doi: https://doi.org/10.1038/d41586-021-00396-2 Page 6 of 6 Once the country has decided to undertake a Country COVID-19 AAR, as an opportunity to strengthen preparedness and the health system, they can refer to the WHO guidance for after action review (AAR) with a few recommended adjustments:  The AAR process should begin with a thorough desk review of all documents related to the response, including all IAR reports if IARs have been conducted in the country to highlight the best practices and challenges already identified.  Select and customize questions from the trigger question database that has been developed for COVID-19 IAR instead of the generic database included in the AAR toolkit. This will allow the use of the same pillars as the IARs and will make the AAR process more streamlined. 5. REFINING COVID-19 IARS AND AARS IN THE EVOLVING GLOBAL CONTEXT As stated in the fourth9 and fifth10 meetings of the International Health Regulations (2005) Emergency Committee regarding the outbreak of coronavirus disease (COVID-19), one of the temporary recommendations issued was for countries to “share best practices, including from intra-action reviews, with WHO; apply lessons learned from countries that are successfully re- opening their societies (including businesses, schools, and other services) and mitigating resurgence of COVID-19.” WHO wishes to further echo this call, and encourages countries to not only conduct IARs more frequently with a focused approach, but also to share their IAR findings through the IAR team11 in WHO and any other platform so other countries can also benefit from this process. As the global context continues to change, follow-up addendums may be developed to better guide countries to maximize learnings from COVID-19 IARs and their transition to COVID-19 AARs. Moving forward, there may also be possible opportunities of using IAR for future protracted health emergencies beyond COVID-19 which may be further explored. © World Health Organization 2021. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. WHO reference number: WHO/2019-nCoV/Country_IAR/add.1/2021.1 9 World Health Organization. (2020) Statement on the fourth meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of coronavirus disease (COVID-19) – Statement dated 1 August 2020. https://www.who.int/news-room/detail/01-08-2020-statement-on-the-fourth-meeting-of-the-international-health-regulations- (2005)-emergency-committee-regarding-the-outbreak-of-coronavirus-disease-(covid-19) 10 World Health Organization. (2020) Statement on the fifth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic – Statement dated 30 October 2020. https://www.who.int/news/item/30-10-2020-statement-on-the-fifth-meeting-of-the-international-health-regulations-(2005)- emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic 11 The IAR team in WHO headquarter can be contacted at: CER@who.int